Midwifery Today Conference News

EPIDEMICS: EPIDURAL ULTRASOUND, INDUCTION, EPISIOTOMY: Learn about the levels
of birth intervention around the world in a stimulating class at Midwifery Today's international conference in Paris, France, 18-22 October 2001.

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Are you a hospital midwife? Now you can learn about appropriate technology, working under restraint, closing the evidence-practice gap, humane hospitals and more.

HypnoBirthing® Institute

Don't be fooled by imitation; insist on the REAL thing. If it doesn't say HypnoBirthing®
Institute, and it doesn't have a capital "B", it's NOT the authentic HypnoBirthing®
program founded by Marie Mongan, Director of the HypnoBirthing® Institute and
author of HypnoBirthing®: A Celebration of Life.

News Flashes

Researchers planned to compare misoprostol to oxytocin for induction of labour
in mothers attempting a VBAC. After two uterine ruptures among just 17 mothers
receiving misoprostol, the trial was stopped on safety grounds. They concluded:
"When misoprostol is used in women with previous cesareans, there is a high
frequency of disruption of prior uterine incisions."

Department of Obstetrics, Northwest Permanente PC, British Columbia, Canada.
Out of 89 women attempting VBAC whose labours were induced with misoprostol, 5
suffered uterine ruptures. However, among 423 women attempting VBAC who did not
receive misoprostol, only one suffered a rupture. The rupture rate for VBAC candidates
after misoprostol induction was therefore 5.6%, compared to 0.2% otherwise.

Misoprostol Induction

The common medical methods of induction in the United States today include intravenous
oxytocin infusion, intravaginal or intracervical dinoprostone, and misoprostol.
Each of these can cause excessive uterine contractility: contractions may be too
forceful, too close together, or too long. When this happens, maternal perfusion
of the placenta is reduced, and the baby may not receive enough oxygen. The degree
of fetal compromise depends on several factors, including the health of the placenta,
the fetal reserves, and the degree of uterine overactivity. Uterine overactivity
also poses risks to the mother. There is a risk of rupture in even the unscarred
uterus. Cervical lacerations are possible. A precipitous second stage can cause
severe vaginal and perineal tears. Excessive contractility can also cause placental
abruption.

When uterine overactivity occurs, an attempt must be made to remove the drug
that is causing the problem. Turning off an oxytocin infusion is fast and easy
and usually results in a rapid return to more normal uterine activity. Some dinoprostone
products are made with a string and are easy to remove quickly. When dinoprostone
gel is used, attempts can be made to flush it from the vagina with sterile saline-clearly
a slower and less effective procedure. With misoprostol, attempts can be made
to remove the pill if it has not yet been absorbed. More often than not, the pill
has already been completely absorbed. In this case there is no choice but to ride
out the excessive contraction pattern with careful monitoring and measures to
maximize the supply of oxygen to the fetus.

Midwifery Today Issue 49 can be ordered from the Midwifery Today storefront
Jennifer Enoch's article is comprehensive and includes nine abstracts of studies
on misoprostol and numerous references.

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An induction with Cytotec should never be attempted anywhere, most especially
in out-of-hospital settings. Incredibly, the American College of Obstetricians
and Gynecologists (ACOG) recently approved Cytotec induction: 1) in spite of lack
of FDA approval; 2) in spite of a letter to doctors earlier this year from Searle
(which manufactures Cytotec) imploring doctors not to use it for induction; 3)
in spite of lack of approval from the Cochrane Library (the best scientific opinion);
and 4) in spite of the fact that it is not approved nor used for induction in
any country in Western Europe.

Recent articles in prestigious medical journals like The Lancet have questioned
the validity of standards of practice from professional organizations like ACOG,
because its goal of protecting the health of women through using scientific evidence
to guide members toward best practices too often conflicts with its other role
as a trade union representing the interest of its members. As a result of this
"trade union" role, ACOG recommendations are too often compromised by
the needs of the obstetricians. A classic example of putting the doctors' needs
ahead of the families' needs is the ACOG recommendation not to permit videotaping
by families of a hospital birth.

So ACOG quotes studies of Cytotec induction, none of which have a sufficient
number of research subjects, and consequently, none of the studies quoted have
sufficient statistical power to detect small but potentially important risks such
as uterine hyperstimulation and uterine rupture. Furthermore, because published
studies of Cytotec induction have such wide methodological variability, meta-analysis
is impossible and the published attempts at such meta-analysis are seriously flawed.
But Cytotec is a godsend for busy obstetricians because its use allows them to
schedule the woman's labor at a convenient time and speeds up the labor, resulting
in a return to "daylight obstetrics"--pharmacological induction of labor
has increased from 10 percent to 20 percent in the past decade in the United States.
So with their members' needs in mind, ACOG plows ahead, ignoring the best scientific
evidence as well as the recommendations of the best scientific bodies, of government
agencies not only in the United States but in every country in Western Europe,
and of the pharmaceutical company. Instead, ACOG uses weak, inadequate evidence
to approve Cytotec induction. Midwives should stay as far away as possible from
such vigilante obstetrics-obstetricians taking matters into their own hands while
ignoring the recommendations of the real judges.

The Farm Midwifery Workshops

The Farm Midwifery Workshops, taught by Ina May Gaskin and The Farm midwives,
strive to teach the skills and knowledge you will need to make the birthing environment
safe, pleasant and responsive to the needs of women and their babies. For more
information with dates, curriculum, and fees, write to us:midwfews@bellsouth.net

Midwifery Today's Online Forum

I am a nurse working with CNMs, and I am going to begin doing vaginal exams
soon. I want tricks, advice, etc. What, exactly, does it feel like? If the cervix
is stretchy, do I call it what it feels, or do I call it what it can stretch to?
How easy/difficult is it to ascertain station? I'm not trying to begin a discussion
on whether or not VE should be performed; we don't do them very often, so I'm
not going to get a whole lot of practice all at once, but it is a skill that I
personally want to learn. If anyone has any tips, please share them!

If you would like to be put on the mailing list to receive a registration packet
please call MAWS at 1-888-422-4784.
MAWS members will automatically receive a packet. www.washingtonmidwives.org

Question(s) of the Quarter for Midwifery Today Issue 60

What are strengths and weaknesses of your path to becoming a midwife? How does
the current controversy over the various pathways to becoming a midwife affect
your practice, or your hopes for a practice? Do you have any specific thoughts
about midwifery education?

I am 24 weeks pregnant and just discovered by ultrasound that I have a placenta
previa. I know that doesn't necessarily mean I will still have a previa at full
term but I am wondering if anyone has the statistics on this. I have seen the
statistics before but I cannot remember where. I will have another ultrasound
closer to term to determine whether it is still an issue, but in the meantime
I would love to have a little peace of mind. Any words of wisdom?

- Anon.

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Anon, who required a transport to hospital [Issue 3:33] appears to have several
issues she needs to address. If she had problems with that particular hospital
she should take them up with that hospital. The management of the hospital may
be able and willing to address them. If not, she owes it to herself and her community
to publicize her experience locally. A global generalization does not help her
community and offends those hospital workers who make every effort to help a diverse
clientele and to treat all support persons regardless of their level of expertise
with dignity and respect.
Without knowing your exact situation I can think of a number of reasons for each
of your concerns--some of them unavoidable, some of them within the realms of
negligence. For yourself and your community, talk to them.

- Jacinta Muller, registered midwife
Australia

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I am 26 weeks pregnant with my third child. I have to have hospital births with
an OB because of a vertical incision from a c-section with my first. For my first
two children there was concern about low body temperatures (I am told this is
a side effect of c-sections) and I want to do what's best to avoid separation
if it occurs again and warm my child myself. Last time I did skin to skin contact
and it worked well enough that the heating lamps weren't needed. Do you feel skin
to skin is best or would it be better to first dress the baby in wool and then
place her in my gown against my breasts?

- Barbara

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